Report 20/2013
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Rail Accident Report Track worker struck by a train at Bulwell, Nottingham 6 August 2012 Report 20/2013 October 2013 This investigation was carried out in accordance with: l the Railway Safety Directive 2004/49/EC; l the Railways and Transport Safety Act 2003; and l the Railways (Accident Investigation and Reporting) Regulations 2005. © Crown copyright 2013 You may re-use this document/publication (not including departmental or agency logos) free of charge in any format or medium. You must re-use it accurately and not in a misleading context. The material must be acknowledged as Crown copyright and you must give the title of the source publication. Where we have identified any third party copyright material you will need to obtain permission from the copyright holders concerned. This document/publication is also available at www.raib.gov.uk. Any enquiries about this publication should be sent to: RAIB Email: [email protected] The Wharf Telephone: 01332 253300 Stores Road Fax: 01332 253301 Derby UK Website: www.raib.gov.uk DE21 4BA This report is published by the Rail Accident Investigation Branch, Department for Transport. Track worker struck by a train at Bulwell, Nottingham, 6 August 2012 Contents Summary 5 Introduction 6 Preface 6 Key definitions 6 The accident 7 Summary of the accident 7 Events preceding the accident 13 Events during the accident 16 Events following the accident 17 The investigation 18 Sources of evidence 18 Key facts and analysis 19 Identification of the immediate cause 19 Identification of causal factors 19 Identification of underlying factors 32 Observations 34 Summary of conclusions 37 Immediate cause 37 Causal factors 37 Underlying factors 38 Observations 38 Previous RAIB recommendations relevant to this investigation 39 Actions reported as already taken or in progress relevant to this report 42 Learning points 43 Recommendations 44 Appendices 46 Appendix A - Glossary of abbreviations and acronyms 46 Appendix B - Glossary of terms 47 Appendix C - Key standards current at the time 52 Report 20/2013 3 October 2013 Bulwell This page is intentionally left blank Report 20/2013 4 October 2013 Bulwell Summary Summary At 09:31 hrs on 6 August 2012, train 2W06, the 09:25 hrs service from Nottingham to Worksop, struck and seriously injured an off-track inspector on the up-down Mansfield line near to Bulwell station, in Nottingham. At the time of the accident, the off-track inspector was undertaking an inspection of lineside vegetation on foot. The off-track inspector was struck by the train because he was standing too close to the track. His awareness of where he was standing had become reduced as he was focused on determining his location. It may also have become reduced because he needed to concentrate on some elements of the inspection. Because the off-track inspector was working on a line open to railway traffic, he had implemented a pre-planned system of work to protect himself from train movements. However, this system of work was unsuitable for the location and task being undertaken. Had the most appropriate type of system of work been planned and implemented, then the accident would have been avoided. The off-track inspector did not realise that the system he was using was unsuitable during the inspection, probably due to the way in which it was implemented. He had also not realised it was unsuitable when the system was issued to him prior to the inspection; this was because the information provided to help him check that it was appropriate did not effectively highlight why it was unsuitable. This system of work was issued to the off-track inspector because the planner who had prepared it was unfamiliar with the location. Information provided to support her decisions about which type of system to use either did not effectively highlight its unsuitability or was found by her to be impracticable to use given her workload. In addition, it had become normal practice within the off-track section to plan and implement the least protective type of system of work for undertaking vegetation inspections. This was, in part, because the section only had a limited range of systems to choose from, but probably also because there was an informal agreement within the section to adopt this practice, which contravened the requirements of Network Rail’s standards. Senior managers were unaware that this had occurred as they were provided with inaccurate safety monitoring data. The increased workload of planners within off-track sections was also identified as a factor in the accident. The RAIB has identified two key learning points. These are: that the relevant Network Rail standard should be observed during the planning, approval and verification of systems of work; and that any incident where a train has struck something whilst passing persons working on or near the line should be initially treated as an accident. The RAIB has also made five recommendations addressed to Network Rail. These relate to: the provision of information to staff about which systems of work have been found to be appropriate for given locations; the monitoring of which system of work types are being used; the resources available within off-track sections to plan and approve systems of work; how previous measures taken by Network Rail to improve the management of systems of work were implemented; and the provision of information to staff regarding the required warning times when working alone. Report 20/2013 5 October 2013 Bulwell Introduction Introduction Preface 1 The purpose of a Rail Accident Investigation Branch (RAIB) investigation is to improve railway safety by preventing future railway accidents or by mitigating their consequences. It is not the purpose of such an investigation to establish blame or liability. 2 Accordingly, it is inappropriate that RAIB reports should be used to assign fault or blame, or determine liability, since neither the investigation nor the reporting process has been undertaken for that purpose. 3 The RAIB’s investigation (including its scope, methods, conclusions and recommendations) is independent of all other investigations, including those carried out by the safety authority or railway industry. Key definitions 4 All dimensions and speeds in this report are given in metric units except speed and locations which are given in imperial units, in accordance with normal railway practice. Where appropriate the equivalent metric value is also given. Location mileages given are measured from a zero datum at St. Pancras station, via Corby. 5 The report contains abbreviations and technical terms (shown in italics the first time they appear in the report). These are explained in appendices A and B. 6 Directions and locations are described in the report as they would appear for a train travelling from Nottingham in the direction of Worksop. Times given for events occurring on 6 August 2012 have been synchronised to match the time coding of the platform CCTV system at Bulwell tram stop. Report 20/2013 6 October 2013 Bulwell The accident Summary of the accident The accident 7 At 09:31 hrs on Monday 6 August 2012, train reporting number 2W06, the 09:25 hrs service from Nottingham to Worksop, struck a track worker on the up-down Mansfield line near to Bulwell station in Nottingham (figure 1). Location of accident © Crown Copyright. All rights reserved. Department for Transport 100039241. RAIB 2013 Figure 1: Extract from Ordnance Survey map showing location of accident 8 The track worker, who was an off-track inspector, suffered serious injuries as a result of the accident. 9 There was no damage to the train or to the infrastructure of the railway as a result of the accident. The line was re-opened to normal service at 14:30 hrs on the day of the accident. Location 10 The accident took place on the up-down Mansfield Line (part of Network Rail’s Robin Hood line) around 55 metres beyond Bulwell South Junction (128 miles 65 chains) and around 140 metres on the approach to the south (Nottingham) end of the platform at Bulwell station (128 miles 76 chains). The railway is single track (with trains travelling in both directions) beyond the junction (figure 2). Report 20/2013 7 October 2013 Bulwell The accident 11 The maximum permitted speed for this type of train when travelling over Bulwell South Junction towards Bulwell station is 55 mph (89 km/h), rising to 70 mph (113 km/h) immediately beyond the junction and through Bulwell Forest CCTV level crossing (129 miles 35 chains). 12 Bulwell South Junction and Bulwell station are situated on a 771 metre radius right-hand curve. Beyond the station, the track becomes straight and remains so through Bulwell Forest CCTV level crossing. 13 The railway at Bulwell is on a north-south axis and is bordered to the west by a tramway. The tram platforms at Bulwell tram stop are situated directly opposite the single railway platform at Bulwell station (figure 2). The infrastructure of the tramway and railway are separated throughout by a high boundary fence. 14 A pedestrian footbridge passes over the tramway and the railway at the north (Worksop/Mansfield) end of Bulwell station. Around 45 metres north of the station, bridge 17B (129 miles 1 chain) carries a main road over the tramway and railway lines. At the time of the accident, a 37 metre length of the line between the north end of the platform and bridge 17B was designated as Red Zone prohibited. Bulwell tram stop Tram lines Bulwell station Route of off-track inspector Route of 2W06 Point of impact Bulwell South Jn Figure 2: Layout of the railway at Bulwell and the routes taken by the train and off-track inspector Organisations involved 15 Network Rail owns and maintains the mainline railway infrastructure at Bulwell and employed the off-track inspector, who was working for its Derby Maintenance Delivery Unit (MDU).